Case presentation
A 61-year-old woman was admitted to our hospital for symptomatic and
drug-resistant paroxysmal atrial fibrillation (PAF) to undergo pulmonary
vein isolation (PVI). She had no significant past medical history.
Transthoracic echocardiography (TTE) showed no cardiac structural
abnormalities with a small left atrium (LA) (LA diameter, 34 mm).
CHADS2-Vasc score was 1 point (female sex), showing a low thromboembolic
risk under optimal oral anticoagulant therapy, and she had taken
rivaroxaban for more than 3 weeks. She had a negative COVID-19 test
result, but we decided to use an intra-procedural intracardiac
echocardiography (ICE) to evaluate left atrial appendage (LAA) for
anatomy and thrombus, as an alternative to pre-procedural
transesophageal echocardiography (TOE) and cardiac computed tomography
(CT). Because, there is almost no risk of thrombus in patients with PAF
under optimal anticoagulation whose CHADS2-Vasc score is 1. Before the
transseptal puncture, ICE depicted an LA mass attached to the atrial
septum, measuring around 15 mm in diameter (Figure 1 ), and the
procedure was discontinued. TOE reveled vascular flow in the stemless
mass, which was 1.7 cm in diameter, and 18F-fluorodeoxyglucose positron
emission tomography (FDG-PET/CT) showed low-level FDG accumulation with
a maximum standardized uptake value of 4.4, and therefore LA myxoma was
suspected. Surgical resection of the intracardiac tumor together with
concomitant surgical PVI was performed, and the histological diagnosis
was cardiac myxoma.